The Acorn & Gaumont House Surgery

Updated 29 September 2022

The Acorn & Gaumont House Surgery is located in Peckham, South London. The practice is situated within the Southwark Clinical Commissioning Group (CCG) and delivers Personal Medical Services (PMS) to a patient population of about 9,000 patients.

Three GPs work full time at the practice, two male and one female. The practice has a team of two nurses, one locum pharmacist and two pharmacists from the local primary care network. The GPs are supported at the practice by a team of reception/administration staff and a practice manager and operations manager.

Each GP provides eight sessions per week, a total 24 sessions per week between all 3 GPs. Clinical sessions including pharmacists and nurses are a total of 28 sessions per week.

Information published by Public Health England shows that deprivation within the practice population group is in the second lowest decile (two of 10). The lower the decile, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is 37.3% White, 43.7% Black, 8.2% Asian, 7% Mixed, and 3.9% Other.

The practice is a GP training practice and is part of south Southwark PCN Improving Health Limited (IHL) GP federation. The practice employs a locum pharmacist to support repeat prescribing and medication review.

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services, family planning and treatment of disease, disorder or injury.

Extended access is provided locally by the GP Extended access service, where late evening and weekend appointments are available. Out of hours services are provided by NHS111.

Updated 29 September 2022

We carried out an announced inspection at The Acorn & Gaumont House Surgery on 25 March 2022. Overall, the practice is rated as inadequate.

Set out the ratings for each key question

Safe - Inadequate

Effective – Requires improvement

Caring - Good

Responsive - Good

Well-led - Inadequate

Following our previous inspection on 6 May 2021 and a remote clinical records review on 4 May 2021, the practice was rated requires improvement overall, and for the Safe, Effective, Caring, Responsive, and Well-led key questions. We served two requirement notices for breaches of Regulation 12 of the Health and Social Care (Regulated Activities) Regulations 2014 (Safe care and treatment) and Regulation 17 of the Health and Social Care (Regulated Activities Regulations 2014 (Good governance).

The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Acorn & Gaumont House Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection to follow up on breaches of regulations and covers our findings in relation to the actions we told the practice they should take to improve.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

• Conducting staff interviews using video conferencing
• Completing clinical searches on the practice’s patient records system and discussing findings with the provider
• Reviewing patient records to identify issues and clarify actions taken by the provider
• Requesting evidence from the provider
• A site visit

Our findings

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We have rated this practice as Inadequate overall.

We found that:

• Clinical and internal audit processes were inconsistent in their implementation and impact. For example, the provider did not have effective oversight of systems to manage safety alerts.
• There were concerns that patients did not receive care, treatment and monitoring for their conditions in line with current guidance and recommendations.
• There were some risks that were not well managed, related to safety risks in the building which were managed by another organisation.
• Systems for reviewing children on the practice’s child protection register had improved.
• The practice had not met targets for cervical screening and childhood immunisations. However, there were robust recall systems and performance against these targets was continually reviewed and monitored.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
• Although GP patient survey results to questions about access to appointments remained below local and national averages, the practice had acted on patient feedback.
• The provider had implemented systems and process in response to the findings of our previous inspection. However, the governance arrangements in place were not effective, especially in relation to identifying, managing and mitigating risks.

We found breaches of regulations. The areas where the provider must make improvements are:

• Ensure that care and treatment is provided in a safe way.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure that persons employed at the practice have received appropriate training.

The areas where the provider should make improvements are:

• Continue to implement a programme to improve uptake for cervical screening and childhood immunisations.
• Improve compliance with policies and procedures; for example, the prescribing policy.
• Improve recording of DNACPR decisions and improve oversight of documenting the decisions made.
• Continue to encourage patients to become members of the patient participation group.

(Please see the specific details on action required at the end of this report). Warning notices were issued to the provider following the inspection undertaken on 25 March 2022. This was to ensure that the provider was aware of our concerns and that action was taken quickly to address these concerns and mitigate risks to patients.

Requirement notices were issued for the additional concerns which related to breaches identified. The level of risk stemming from these concerns was not deemed to be sufficient to require additional enforcement action.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement, we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care